Transitions of care: Successes and discoveries

A MEDS Ed seminar

This session of CareOregon Pharmacy’s MEDS Ed program focuses on recent discoveries and lessons learned across transitional care environments, including hospital discharge, Skilled Nursing, and Meds-to-Beds. 

Content from Jane Duck and Mariah Alford provides an overview of the most common causes of 30-day readmissions.

Content from Jane Duck reviews root cause analysis of the discharge process and readmission examples.

Content from Mai Tran and Anthony Neises reports on their partnership in an ongoing bedside medication delivery pilot, working between health plan and hospital pharmacists to help reduce hospital readmissions.

Content from Nate Semm and Elizabeth Decker reviews the hospital discharge process, including the successes and barriers encountered in care management.

Content from Carlo De Gregorio provides insight into the work done piloting high-risk patient huddles to examine all ED and hospital admissions, along with outreach efforts to reduce readmissions.

Content from Meryl Manley reveals the inner workings and structural environments of Skilled Nursing Facilities and their critical role in the discharge process.

Content from Elizabeth Whitworth explains EDIE and PreManage systems and the value they bring to coordinated care and shared workflows.

Q & A segment with the entire Transitions of Care presenter panel.

Featured speakers

• Jane Duck, RN, BSN – High Risk Populations Program Manager, CareOregon
• Mariah Alford, PharmD, BCPS – Pharmacy Clinical Supervisor, CareOregon 
• Mai Tran, PharmD, BCACP, BCGP – CareOregon
• Anthony Neises, PharmD, – Legacy Health
• Nate Semm, CSWA, – Legacy Health
• Elizabeth Decker, RN Case Manager – Legacy Health
• Carlo De Gregorio, Health Assistant – Pioneers Care Team – Central City Concern
• Meryl Manley, RN, PCCN – Post-Acute Care Manager – Prestige Care
• Elizabeth Whitworth, MPH – PreManage Project Manager – CareOregon 

Transitions of Care Slide Deck